School Health Information Form

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

This form should be completed annually for students in Pine Island Public Schools. This is typical filled out when a student enters 5th and 9th grades. It is also needed for all students that are new to the district. This form should also be completed for students that are being evaluated for special education or 504 plans.

Email *

Student's Name *

Student's date of birth *

YYYY

Student's grade *

Health History:

Check all conditions your child has or has been treated for in the past.
Please explain if condition(s).
List any medications that child is taking related to that condition.

Diabetes

Seizures

Allergies (Food, Animal, Environment) please be specific

Lung/ Respiratory Disease (Asthma)

Heart/Cardiovascular Conditions

Head Injury/Concussion

Behavior or Emotional Difficulties

Autism or Attention Disorders (ADD, ADHD)

Neurological Disorders

Mental Health Conditions (e.g. Anxiety, Depression)

Fainting Spells and Dizziness

Kidney/Bladder Conditions

Ear/Eyes/Nose/Sinus Problems

Muscle or Bone Conditions

Abdominal/Stomach/Digestive Problems

Migraines or Severe Headaches

Food Restrictions/Special Diet

Skin Conditions

Mobility Problems or Activity Restrictions

Learning Problems

Vision Concerns

Vision Concerns:

Yes- Wears both glasses and/or contacts

No- Does not wear glasses or contacts

Other:

Date of last professional eye exam

YYYY

Results of the eye exam

Hearing Concerns

Hearing Devices

Yes- Student has a hearing device

Hearing device is in Left Ear

Hearing device is in Right Ear

Hearing device in Both Ears

No hearing device is required

Other:

Please share any other medical concerns or conditions you may have about your child.

Please list any medications (prescription, over the counter, inhalers, epipens etc.) or supplements your child is taking at home and school.

***Please include the medication name, dose, frequency and reason.

***REMEMBER to complete on an annual basis the required self carry form with the school nurse for ANY over the counter pain relief medications or inhalers/epipens your child may want to self carry.

Would you like to schedule a conference with the licensed school nurse to discuss a particular health concern

Yes

Clear selection

The information you provide will only be shared with school staff who required access to this information to meet your child's health and safety needs while at school. Not providing complete and accurate information may result in an incomplete health and safety plan for your child.

Parent/ Guardian Signature *

Best contact phone number to use if we need to contact you with any questions.

A copy of your responses will be emailed to the address you provided.

Submit

Clear form

Never submit passwords through Google Forms.

reCAPTCHA

Privacy Terms

This form was created inside of Pine Island Public Schools ISD 255. Report Abuse

Forms